David B. Resnik, Ph.D.
Pain is the principal reason why patients see physicians but it is routinely under-treated in health care. Many recent studies have demonstrated inadequate pain management in many different circumstances, including pain in terminal illness, pain in elderly populations, chronic pain, pain in emergency care, and post-operative pain. This is by no means a new problem in health care. For more than 25 years researchers have documented the under-treatment of pain. In the last decade, many medical professionals, professional organizations, and scholars have decried this problem and have championed the cause of better pain control.
To better understand this problem, pain specialists, social scientists, and policy researchers have identified a long list of reasons why pain is often under-treated. These include:
(A) Medical professionals receive inadequate education on pain assessment, pain treatment and palliative care;
(B) Medical professionals face legal and regulatory pressures to restrict the use of narcotics to treat pain;
(C) Medical professionals, patients, and families are concerned about the probable or possible side-effects of analgesics, such as sedation, dizziness, nausea, constipation, increased cardiac load, decreased renal function, tolerance, physical dependence, and addiction;
(D) Medical professionals sometimes believe that patients are overstating, imagining, or faking their pain;
(E) Patients are hesitant to talk to medical professionals about pain because they do not want to distract medical professionals from their “real” diseases or they think an increase in pain means that their disease is getting worse;
(F) Patients want to feel some pain because they view pain as an overall indicator of their health or they think it is virtuous to suffer;
(G) Health care organizations, government agencies, and insurers do not provide adequate funding for pain control; and
(H) The medical community has not conducted enough research on pain management and palliative care.
In response to the problem of pain undertreatment, advocates for better pain control have made a number of different proposals, including more research and education on pain assessment and treatment, better funding for pain control, and legal and regulatory reforms to support adequate pain control. These calls for better pain control come in the wake of a widespread recognition of the role of palliative care in dying patients, and the importance of adequate palliation in reducing the demand for euthanasia and physician-assisted suicide.
Despite reams of data on the under-treatment of pain and a chorus of voices calling for better pain control, the problem persists. Although the reasons mentioned above help to explain the phenomena of under-treated pain, they do not tell the whole story. If the under-treated condition were an objective health problem, such as diabetes, then researchers would seek to understand the disease and develop new treatments, medical professionals would take the time to learn how to manage diabetes, patients would insist on being treated for diabetes, and insurance companies and government agencies would provide adequate funding to support therapy and prevention.
The crux of the problem of pain undertreatment is that pain is not like other objective medical problems, such as diabetes. To understand why pain is so often under-treated, we must place pain in its larger cultural and philosophical context. By viewing the problem from this perspective, one can see that one reason why medical professionals undertreat pain is that it does not fit in well with the scientific approach to health and disease, a philosophy adopted by most medical professionals. Pain is fundamentally subjective and does not fit neatly into the causal/ explanatory/clinical structure of scientific medicine. Pain is therefore often viewed as “unreal,” “unimportant,” or “merely psychological.” To understand why modern medicine has difficulties with pain management, it will be useful to first examine several of medicine’s philosophical assumptions.
The Objective Approach to Diagnosis
Today’s health care professionals use objective methods, such as blood tests, urinalysis, x-rays, CT scans, and biopsies, to develop and confirm diagnoses. These tests allow clinicians to observe, measure, quantify, and compare various anatomical, biochemical, and physical properties, structures, and functions to determine the presence of a specific disease. Statistical methods allow clinicians to develop normal ranges for various measurements, such as blood pressure, and normal images for various structures, such as the lung. Medical testing has become highly technological, specialized, and expensive.
The Causal-Mechanical Approach to Explanation
To understand and explain diseases, medical professionals use causal-mechanical models of the body and its processes. According to modern medicine, diseases are specific entities, structures, processes, or properties that produce various symptoms, including pain, injury, and disability. Diseases affect the body and mind by means of various biochemical, biomechanical, and physiological mechanisms. For example, ear infections are diseases caused by specific pathogens, such as bacteria that cause otitis media. It produces various symptoms, such as an earache and a fever. Diabetes mellitus is a disease caused by the body’s failure to respond to insulin. Its symptoms include elevated blood sugar, excessive urination, and the presence of sugar in the urine. One natural implication of the causal-mechanical approach to medicine is a commitment to understand and control underlying causes, such as diseases, not mere effects, such as symptoms. Although medicine attempts to relieve symptoms, the goal of therapy is to diagnose, cure or prevent underlying diseases that produce symptoms. Clinicians are taught to do more than merely “manage” symptoms: they are taught to diagnose, treat, and cure diseases.
Modern medicine has developed an impressive array of surgical and pharmaceutical interventions (or “magic bullets”) that can be used to treat and cure diseases. This approach to treatment fits in well with the causal-mechanical approach to disease, since pharmaceutical methods treat the body as a biochemical system, and surgical methods treat the body as a biomechanical system. Although this approach has been very successful in treating and preventing a variety of acute illnesses and injuries, such as appendicitis, a broken arm, or polio, it has been less successful in treating chronic conditions, such as arthritis, diabetes, lower back pain, which often can be controlled but not cured. This approach also has limited success with conditions that require a multi-disciplinary framework, such as clinical depression, asthma, and alcoholism.
Health care professionals, like scientists, are regarded as having expert knowledge, skills, experience, and judgment. This expertise imposes additional responsibilities on medical professionals, but it also grants them extra privileges and authority. Professional, legal, social, and ethical norms also reflect this expert model of health care. To become a health care expert, one must undergo many years of education and training, subscribe to an ethical code, and meet licensing requirements. Like scientists, medical professionals have developed a highly specialized technical language pertaining to their areas of expertise. Patients see doctors, in part, because they believe that doctors have some special, expert knowledge of health and disease.
The preceding characterization of some of the assumptions of modern medicine provides us with a cultural and philosophical context for understanding some reasons why medical professionals often under-treat pain.
Pain and Objectivity
Pain is a subjective feeling or sensation that is perceived as unpleasant. Pain is what the patient says it is, where the patient says it is, when the patient says it is. In order to assess pain, medical professionals must rely on first-person reports from patients. Although some patients fake their pain, medical professionals should believe their patients’ reports of pain unless they have good evidence that they are not telling the truth. Because pain is subjective, it is also private. Although we all know what pain feels like, we will never be able to experience someone else’s pain. We can no more experience another person’s pain than we can experience their joy, their love of Mozart, their aversion to anchovies, or their suffering.
Because pain is subjective, patients can control their responses to pain by learning to cope with pain. Two different people have the same injury, such as a broken arm, but respond differently to it as a result of differences in their coping skills. Patients can learn to cope with pain by learning to focus their attention on aspects of their experience other than the pain and by giving the painful sensation a positive interpretation. For example, a long distance runner may cope with the pain resulting from muscle fatigue by focusing her attention on her surroundings. During labor, a woman may cope with the pain of childbirth by giving it a positive interpretation, e.g. the pain is part of the miracle of birth. Because the response to pain depends on coping skills, people exhibit great variation in their tolerance for pain, which can contribute to skepticism about the reality or importance of pain.
The subjective aspects of pain interfere with its incorporation into modern medicine, which tends to focus on objective aspects of health. Although health care professionals are taught to talk to patients about pain and to include pain assessment in the initial examination and case history, they tend to put more weight on objective tests and measurements. A high blood pressure reading, an abnormal Pap smear, or a fever tends to speak more loudly and forcefully than a report of unremitting pain. Medical charts include dozens of entries pertaining to lab values, x-rays, vital signs, and other objective tests, but pain is rarely mentioned. For better or worse, medical professionals place a great deal of faith in objective (i.e. scientific) tests and measurements. Since pain is subjective, it is often viewed as less important than objective aspects of patient care, such as diagnostic testing. In medicine, facts tend to drive out feelings.
In order to overcome this problem, pain specialists have developed a variety of pain assessment tools, such as pain scales, journals, and surveys. Some organizations have even proposed that pain be viewed as a “fifth vital sign.” I endorse these tools and this proposal. However, pain assessment tools will never achieve the degree of objectivity that one finds in most medical tests, since pain will still be a subjective sensation or feeling. As long as we rely on first-person reports of pain, we cannot expect to develop fully objective tests of pain, and many people will continue to underrate its importance and doubt patients’ reports of pain.
One might argue that one can solve this conundrum by circumventing first-person reports of pain. In theory, one could also develop objective tests of pain based on current and expected advances in medicine and neurobiology. For example, suppose that it is one day possible to use instruments to determine the activity of the nociceptive system, i.e. that we could scan the nervous system for pain in the way we can use an EEG to detect Alzheimer’s disease or epilepsy. As we noted in our earlier discussions, however, there are inherent limits to physiological tests for pain, since pain is a sensation that is consciously experienced. Some types of painful sensations may be associated with specific types of physiological mechanisms, such as noxious stimuli, the firing of nociceptors, etc., but pain cannot be identified with types of physiological mechanisms. A test for a “pain mechanism” could tell us, at best, that a person is probably in pain or probably not in pain, but since pain is subjective, it would not give us any definite answers. To describe and explain subjective qualities of the human experience, such as pain, we must rely on first-person reports.
Pain and the Causal-Mechanical Approach to Medicine.
Many types of pain, especially neuropathic pain, are not fully understood. Some of the most baffling types of chronic pain, such as phantom limb pain, postherpetic neuralgia, and fibromyalgia, are neuropathic pains. In neuropathic pain, the neurons that transmit pain signals to the central nervous system are functioning improperly, and this causes stimuli that are normally perceived as innocuous to be perceived as painful. Very often, it will be difficult to discern the nature of the neural pathology or its etiology even though the patient is in a great deal of pain. If a medical professional does not understand the cause of the patient’s pain, he or she may doubt whether the pain is real.
One can recognize that a medical phenomenon is real even when one does not understand its causal basis. Pain can be real even when we do not understand the causes of pain. As far as the sensation of pain is concerned, the axiom “to be is to be perceived” applies. This view does not square with the causal-mechanical approach to disease, however, which embodies that axiom, “to be is to have a causal basis.” When medical professionals do not know or understand the causal basis of any medical condition, they frequently view the condition as not real. Reports of pain may be viewed as imaginary, fraudulent, or “merely” psychological. It should be noted that pain is not unique in this respect, since medical professionals have had a difficult time coming to terms with other similar medical conditions, such as chronic fatigue syndrome and Gulf War syndrome.
This approach to pain, though common, is fallacious and simplistic. This approach is fallacious because understanding the causal basis for a medical condition should not be a requirement for assigning that condition a reality or existence. For many years, physicians did not understand the causal basis of epilepsy, cerebral palsy, and cancer, yet these conditions were real and continue to be real. Until the 19th century, physicists did not understand the causal basis of electricity and magnetism, yet these phenomena were and are real. Neurobiologists still do not understand the causal basis of human consciousness, yet consciousness is real. These same points apply to the reality of pain.
This approach to pain is simplistic as well, since it ignores the fact that sensations of pain that have no well-established physiological basis may still have psychological causes. Psychological causes, even if highly complex, are still real causes. A person’s headache may be caused by an emotional disturbance, but this does not mean that the headache (or its causes) is not real. Even “faked” pain may have psychological causes, such as addiction and depression. Human suffering related to the loss of a loved one, traumatic stress, or illness, can also cause a person to feel pain. As long as we accept a materialistic approach to the mind-body problem, then we should assume that mental phenomenon, such as pain and other sensations, fit into the causal structure of the world and that psychological causes are real causes.
When pain is recognized as real, medicine’s emphasis on treating diseases instead of symptoms may encourage some medical professionals to gives pain less priority in patient care than it deserves. Since pain is a “mere” symptom and not a disease, pain treatment may be given less emphasis in a patient’s plan of care. Other important concerns in therapy, such as prolonging life and restoring health, may be viewed as more important than pain management. Pain control, according to those who adopt this attitude, is icing on the medical cake.
This view also rests on a misunderstanding of medical practice and the goals of medicine. For conditions that can be cured or effectively treated, such as appendicitis, gallstones, or a deep laceration, promoting life and restoring health should be the primary goals of therapy. However, many conditions cannot be cured or effectively treated. When a patient is terminally ill, the primary goals of therapy should be palliative, not curative. When a patient suffers from chronic pain due to a disease or a chronic pain syndrome, pain may be the only problem that can be effectively treated. When curative goals cannot be effectively achieved, medicine should become more palliative in its approach.
Pain and Magic Bullets
Medical professionals now have a variety of pharmaceutical and surgical techniques for relieving pain. These “magic bullets” produce analgesia by treating the body as biochemical/ biomechanical system. However, since there are also important psychological, social, cultural, and spiritual aspects to pain, this approach to pain control has inherent limitations. To achieve effective pain relief, it is often necessary to use non-pharmacological and non-surgical treatment modalities, such as psychotherapy, massage, exercise, and so on. Pain control is a complex problem that requires a multi-disciplinary approach.
Unfortunately, it is often not easy for medical professionals and patients to adapt to this multi-disciplinary model, since non-pharma-ceutical and non-surgical methods may require considerable education, patient responsibility and compliance, and followup. It is much easier for a physician to write a prescription for low back pain or recommend surgery, than it is for her to develop and implement a plan of care that involves exercise, massage, music therapy, and psychotherapy. It is also easier for the patient to take a drug for pain than it is to follow a multi-disciplinary program for pain management. The remarkable advances in medicine that have occurred in this century have led us to expect a “magic bullet” for all of our medical problems, including pain. Unfortunately, we still lack easy and quick fixes for many of our difficult medical problems, such as pain.
Pain and Expert Knowledge
Finally, pain does not completely fit the model of expert knowledge that we find in medicine, science, and other professions. Although expert knowledge is required in order to understand the causal basis of pain and recommend treatments for pain, no expertise is required to observe pain. This point can be related to the subjectivity issues we have already discussed at length: as far as their own sensations of pain are concerned, patients are the experts. Patient expertise reverses the usual model of doctor-patient relationships by placing knowledge and authority in the hands of patients, not health care professionals. Although pain experts have developed some specialized terms relating to pain assessment and treatment, this terminology has not yet been completely adopted by health care professionals. Moreover, pain expertise, such that it is, has not been propagated very far in the medical profession, since there is still very little discussion of pain management in medical, nursing, and pharmacy education.
One might argue that medical professionals can solve the expertise problem by conducting more research on pain, by promoting pain education in medical, nursing, and pharmacy schools, and by developing and refining the terminology used to discuss pain. I agree with these proposals. However, there are some inherent limits to the applicability of the expertise model to pain. Even if health care professionals develop and adopt an expert language for talking about pain, it is likely that the majority of patients will not understand or use this language, since many people find medical jargon to be baffling and intimidating. ‘Pain,’ ‘itch,’ ‘red,’ ‘loud,’ ‘soft,’ and other terms that describe sensations are likely to remain part of our common vernacular or “folk” psychology. Since health care professionals must rely on first-person reports of pain in order to assess and treat pain, any expert language for talking about pain must allow medical professionals to explain and interpret reports of pain that are expressed in vernacular. Thus, even “scientific” or “expert” theories and concepts of pain must still maintain strong ties to the common experience of pain, since the usefulness of these theories and concepts will depend on their applicability to the clinical setting. Since pain research and education are based on our theories and concepts of pain, the common experience of pain also restricts or shapes pain research and education. Pain experts, unlike experts in physics, mathematics, cardiology, or molecular genetics, cannot stray very far from the common experience of pain.
Conclusion: Reforming Medicine
In this essay, I have argued that one reason why medical professionals often under-treat pain is that pain does not fit in well with the scientific approach to medical practice. Pain does not fit this approach because pain is subjective; the causal basis of pain is often poorly understood; pain is often viewed as a “mere” symptom, not as a disease; there often are not “magic bullets” for pain; and pain does not fit the expert knowledge model. In order for health care professionals to do a better job of treating pain, some changes need to occur in medical philosophy, education and practice. Many other writers have recommended legal, regulatory, financial changes in health care in order to promote better pain management. I also believe that some changes need to occur in health care in order to support and improve the quality of pain control. My discussion of the relationship between pain and scientific medicine suggests that the required changes should go far beyond legal, regulatory, and financial remedies, since these solutions fail to address some of the deeper causes of inadequate pain medicine. Since the inadequate treatment of pain is due, in part, to the nature of modern medicine, adequate pain treatment depends on a deliberate effort to rethink medical education, practice, and philosophy. Some of the assumptions that work so well for so many medical problems need to be dropped or relaxed when it comes to the assessment and treatment of pain. To help bring about this transformation, I suggest the following steps
1. Health care professionals should receive more education on pain management. Discussion of pain management should take place in pre-professional and post-professional settings.
2. Health care professionals should talk about pain more in a clinical setting Discussions should take place between patients and the medical team as well as among team members. Conferences about the plan of care for a patient should address pain management issues.
3. Health care professionals should become more comfortable with the subjective aspects of pain. Medical professionals should be willing to believe patient’s reports of pain even when the causal basis of the pain is poorly understood.
4. Pain assessment results should be treated like other test results and should be recorded in the patient’s medical record. Pain should become a “fifth vital sign.”
5. Health care professionals and patients should be more open to an inter-disciplinary approach to pain management, especially when pharmaceutical and surgical techniques are not effective. Other techniques, such as psychotherapy, hypnosis, distraction, and massage, should be employed in pain treatment. Medical professionals and patients should not expect a “magic bullet” exists that can cure any pain.
These steps will not solve all the problems with pain under-treatment, but they will help medical professionals do a better job of dealing with pain. Since pain under-treatment is due, in part, to beliefs and attitudes that play a foundational role in modern medical philosophy and practice, it will not be easy for our society to take these steps. However, the end result—better pain management—will be worth the effort.
(This article is based on Resnik D, Rehm M, and Minard R. The under-teatment of pain: scientific, clinical, and philosophical factors. Medicine, Health Care and Philosophy 2001; 4: 277-288. Full references can be found in that essay.)